A systematic review of population-based studies examining outcomes in primary retroperitoneal sarcoma surgery

Retroperitoneal sarcomas (RPS) are rare mesenchymal tumours. Their rarity challenges our ability to understand expected outcomes. The aim of this systematic review was to examine 30-day morbidity and mortality, overall survival rates and prognostic predictors from population-based studies for patients undergoing curative resection for primary RPS. A systematic literature review of EMBASE, MEDLINE, PUBMED and the Cochrane library was performed using PRISMA for population-based studies reporting from nationally registered databases on primary RPS surgical resections in adults. The main outcomes evaluated were 30-day morbidity and mortality and overall survival rates. The use of additional treatment modalities and predictors of overall survival were also examined. Fourteen studies (n = 12 834 patients) reporting from 3 national databases, (Surveillance, Epidemiology and End Results (SEER), the United States National Cancer Database (US NCDB) and the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP)) were analysed. The reported overall 30-day morbidity and mortality were 23% (n = 191/846) and 3% (n = 278/10 181) respectively. Reported use of perioperative radiotherapy was 28%. No study reported loco-regional recurrence rates. Overall reported 5-year survival ranged from 52% to 62%. Independent predictors of overall survival were age of the patient, resection margin, tumour grade and size, histological subtype and receipt of radiotherapy. This review of population-based data demonstrated relatively low 30-day morbidity rates in patients undergoing curative surgical resections for primary RPS. Thirty-day mortality rates were similar to other abdominal tumour groups. There remains a paucity of data reporting recurrence rates, however 5-year survival rates ranged from 52 to 62%.

Significance of Anemia in Outcomes After Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer

BACKGROUND

Approximately one quarter of patients receiving neoadjuvant chemoradiotherapy (NCRT) for locally advanced rectal cancer will be anemic at presentation. The outcomes of these anemic patients have historically been less favorable. We assessed the potential of anemia to act as an independent biomarker for a poor prognosis in patients with locally advanced rectal cancer.

MATERIALS AND METHODS

We performed a retrospective, observational study of consecutive patients with locally advanced rectal adenocarcinoma who underwent NCRT from 2004 to 2009 at 3 English National Health Service trusts. The main outcomes were Rectal Cancer Regression Grade, mortality rate, and disease-free survival. These were compared between the anemic and nonanemic patients.

RESULTS

A total of 273 patients were included. Of these patients, 63 (23%) had a hemoglobin level of < 120 g/L (anemic) at presentation. The Rectal Cancer Regression Grades were higher (less regression) in the anemic patients than in the nonanemic patients (χ² = 10.14; P = .006). A subgroup analysis stratified by disease stage at presentation demonstrated less tumor regression in anemic patients with Dukes stage C disease (Dukes stage B, χ² = 4.31, P = .12; Dukes stage C, χ² = 5.36, P = .07). After adjusting for age, gender, and initial Dukes stage, the anemic patients demonstrated greater mortality rates than the nonanemic patients (hazard ratio, 1.73; 95% confidence interval, 1.05-2.86). The consistency with which the 2 independent reviewers were able to generate the rectal cancer regression grades from the historic pathology reports varied. Also, the subgroup analyses in the present study were often limited by low power.

CONCLUSION

The present large UK study examined patients receiving NCRT for magnetic resonance imaging-proven, locally advanced rectal adenocarcinoma. Our findings have demonstrated that patients who were anemic at presentation have higher regression grades (less regression) in response to the treatment than nonanemic patients. This trend appeared to persist despite radiologic disease stage at presentation. Anemia at presentation was also associated with increased mortality rates compared with that of nonanemic patients.

Dressings for the prevention of surgical site infection

BACKGROUND

Surgical wounds (incisions) heal by primary intention when the wound edges are brought together and secured, often with sutures, staples, or clips. Wound dressings applied after wound closure may provide physical support, protection and absorb exudate. There are many different types of wound dressings available and wounds can also be left uncovered (exposed). Surgical site infection (SSI) is a common complication of wounds and this may be associated with using (or not using) dressings, or different types of dressing.

OBJECTIVES

To assess the effects of wound dressings compared with no wound dressings, and the effects of alternative wound dressings, in preventing SSIs in surgical wounds healing by primary intention.

SEARCH METHODS

We searched the following databases: the Cochrane Wounds Specialised Register (searched 19 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library 2016, Issue 8); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations, MEDLINE Daily and Epub Ahead of Print; 1946 to 19 September 2016); Ovid Embase (1974 to 19 September 2016); EBSCO CINAHL Plus (1937 to 19 September 2016).There were no restrictions based on language, date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing wound dressings with wound exposure (no dressing) or alternative wound dressings for the postoperative management of surgical wounds healing by primary intention.

DATA COLLECTION AND ANALYSIS

Two review authors performed study selection, 'Risk of bias' assessment and data extraction independently.

MAIN RESULTS

We included 29 trials (5718 participants). All studies except one were at an unclear or high risk of bias. Studies were small, reported low numbers of SSI events and were often not clearly reported. There were 16 trials that included people with wounds resulting from surgical procedures with a 'clean' classification, five trials that included people undergoing what was considered 'clean/contaminated' surgery, with the remaining studies including people undergoing a variety of surgical procedures with different contamination classifications. Four trials compared wound dressings with no wound dressing (wound exposure); the remaining 25 studies compared alternative dressing types, with the majority comparing a basic wound contact dressing with film dressings, silver dressings or hydrocolloid dressings. The review contains 11 comparisons in total.

PRIMARY OUTCOME

SSIIt is uncertain whether wound exposure or any dressing reduces or increases the risk of SSI compared with alternative options investigated: we assessed the certainty of evidence as very low for most comparisons (and low for others), with downgrading (according to GRADE criteria) largely due to risk of bias and imprecision. We summarise the results of comparisons with meta-analysed data below:- film dressings compared with basic wound contact dressings following clean surgery (RR 1.34, 95% CI 0.70 to 2.55), very low certainty evidence downgraded once for risk of bias and twice for imprecision.- hydrocolloid dressings compared with basic wound contact dressings following clean surgery (RR 0.91, 95% CI 0.30 to 2.78), very low certainty evidence downgraded once for risk of bias and twice for imprecision.- hydrocolloid dressings compared with basic wound contact dressings following potentially contaminated surgery (RR 0.57, 95% CI 0.22 to 1.51), very low certainty evidence downgraded twice for risk of bias and twice for imprecision.- silver-containing dressings compared with basic wound contact dressings following clean surgery (RR 1.11, 95% CI 0.47 to 2.62), very low certainty evidence downgraded once for risk of bias and twice for imprecision.- silver-containing dressings compared with basic wound contact dressings following potentially contaminated surgery (RR 0.83, 95% CI 0.51 to 1.37), very low certainty evidence downgraded twice for risk of bias and twice for imprecision. Secondary outcomesThere was limited and low or very low certainty evidence on secondary outcomes such as scarring, acceptability of dressing and ease of removal, and uncertainty whether wound dressings influenced these outcomes.

AUTHORS' CONCLUSIONS

It is uncertain whether covering surgical wounds healing by primary intention with wound dressings reduces the risk of SSI, or whether any particular wound dressing is more effective than others in reducing the risk of SSI, improving scarring, reducing pain, improving acceptability to patients, or is easier to remove. Most studies in this review were small and at a high or unclear risk of bias. Based on the current evidence, decision makers may wish to base decisions about how to dress a wound following surgery on dressing costs as well as patient preference.

Dressings for the prevention of surgical site infection

BACKGROUND

Surgical wounds (incisions) heal by primary intention when the wound edges are brought together and secured - often with sutures, staples, clips or glue. Wound dressings, usually applied after wound closure, provide physical support, protection from bacterial contamination and absorb exudate. Surgical site infection (SSI) is a common complication of surgical wounds that may delay healing.

OBJECTIVES

To assess the effects of wound dressings for preventing SSI in people with surgical wounds healing by primary intention.

SEARCH METHODS

In February 2014 we searched: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); The Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); The Health Technology Assessment Database (HTA) (The Cochrane Library); NHS Economic Evaluation Database (NHSEED) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. There were no restrictions based on language or date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing alternative wound dressings or wound dressing with no dressing (wound exposure) for the postoperative management of surgical wounds healing by primary intention.

DATA COLLECTION AND ANALYSIS

Two review authors performed study selection, risk of bias assessment and data extraction independently.

MAIN RESULTS

Twenty RCTs were included (3623 participants). All trials were at unclear or high risk of bias. Twelve trials included people with wounds resulting from surgical procedures with a contamination classification of 'clean', two trials included people with wounds resulting from surgical procedures with a 'clean/contaminated' contamination classification and the remaining trials evaluated people with wounds resulting from various surgical procedures with different contamination classifications. Two trials compared wound dressings with leaving wounds exposed. The remaining 18 trials compared two alternative dressing types. No evidence was identified to suggest that any dressing significantly reduced the risk of developing an SSI compared with leaving wounds exposed or compared with alternative dressings in people who had surgical wounds healing by primary intention.

AUTHORS' CONCLUSIONS

At present, there is insufficient evidence as to whether covering surgical wounds healing by primary intention with wound dressings reduces the risk of SSI or whether any particular wound dressing is more effective than others in reducing the rates of SSI, improving scarring, pain control, patient acceptability or ease of dressing removal. Most trials in this review were small and at high or unclear risk of bias. However, based on the current evidence, we conclude that decisions on wound dressing should be based on dressing costs and the symptom management properties offered by each dressing type e.g. exudate management.

A randomised controlled trial of the efficacy of ultrasound-guided transversus abdominis plane (TAP) block in laparoscopic colorectal surgery

BACKGROUND

Optimal analgesia following laparoscopic colorectal resection is yet to be determined; however, recent studies have questioned the role of postoperative epidural anaesthesia, suggesting other analgesic modalities may be preferable. The aim of this randomised controlled trial was to assess the effect of transversus abdominis plane (TAP) blocks on opioid requirements in patients undergoing laparoscopic colorectal resection.

METHODS

After appropriate trial registration ( www.clinicaltrials.gov NCT 00830089) and local medical ethics review board approval (REC 09/H0407/10), all adult patients who were to undergo laparoscopic colorectal surgery at a single centre were randomised into the intervention group receiving bilateral TAP blocks or the control group (no TAP block). The blocks were administered prior to surgery after the induction of a standardised anaesthetic by an anaesthetist otherwise uninvolved with the case. The patient, theatre anaesthetist, surgeon, and ward staff were blinded to treatment allocation. All patients received postoperative analgesia of paracetamol and morphine as a patient-controlled analgesia (PCA). Cumulative opioid consumption and pain scores were recorded at 2, 4, 6, and 24 h postoperatively and compared between the groups as were clinical outcomes and length of stay.

RESULTS

The intervention (TAP block) group (n = 33) and the control group (n = 35) were comparable with respect to characteristics, specimen pathology, and type of procedure. The TAP block group's median cumulative morphine usage (40 mg [IQR = 25-63]) was significantly less than that of the control group (60 mg [IQR = 39-81]). Pain scores and median length of stay (LOS) were similar between the two groups.

CONCLUSION

Preoperative TAP blocks in patients undergoing laparoscopic colorectal resection reduced opioid use in the first postoperative day in this study.

Does the incidence of unexpected malignancy in 'benign' rectal neoplasms undergoing trans-anal endoscopic microsurgery vary according to lesion morphology?

AIM

Mucosectomy by trans-anal endoscopic microsurgery (TEMS) allows safe and effective excision of benign rectal lesions. Preoperative endoscopic, clinical and ultrasonographic assessment aims to select benign lesions whilst avoiding inappropriate mucosectomy in lesions with malignancy. This study examines the relationship between lesion morphology and accurate benign preoperative classification of rectal lesions undergoing TEMS.

METHOD

Primary lesions preoperatively assessed as benign were identified from a prospective TEMS database. Operative specimen morphology was independently classified by two blinded investigators, using photographs, into flat-sessile, exophytic or mixed morphology. The accuracy of the preoperative assessment by rectal ultrasonography was compared with the results of histological examination of the excised specimen (χ(2) and Fisher's exact tests).

RESULTS

Of 167 lesions with adequate data, the morphological classification showed 60 flat-sessile, 56 mixed morphology and 51 exophytic tumours, of which 5, 7 and 9, respectively, contained unexpected malignancy (P=0.48). Accurate preoperative assessment of a lesion as benign occurred in 89% of flat-sessile and mixed morphology (n=55 and 49, respectively) and in 70% of exophytic lesions (n=36) (P=0.01). Only the exophytic group contained patients in whom preoperative endoscopic and ultrasonographic staging could not be confidently made (uTx). Histology demonstrated six of the seven uTx cases to be benign.

CONCLUSION

In this study exophytic polyps were less likely to be accurately classified as benign using preoperative ultrasonography/endoscopy when compared with flat-sessile or mixed morphology polyps.

Prevalence and significance of anaemia in patients receiving long-course neoadjuvant chemoradiotherapy for rectal carcinoma

AIM

The study aimed to assess the prevalence and significance of anaemia during long-course neoadjuvant radiotherapy for rectal cancer at our centre.

METHOD

Hospital coding and a prospective oncology database were used to identify all patients undergoing long-course neoadjuvant radiotherapy for rectal cancer at our centre between 2004 and 2009. A retrospective review of computerized records was used to extract individual patient data. Anaemia was defined as a haemoglobin level of < 11.5 g/dl for women and of < 13 g/dl for men. Downstaging was assessed by comparing radiological stage (rTNM) with histological stage (ypTNM). Tumour regression after radiotherapy was assessed using the Rectal Cancer Regression Group (RCRG) scores of 1-3. The results were analysed using Gnu PSPP statistical software.

RESULTS

There were 70 patients (51 men) of median age 66 (interquartile range 60-72.75) years. Of these, 24 were anaemic. Two (3%) had no haemoglobin level recorded and were excluded. Forty-two per cent of anaemic patients demonstrated mural (T) downstaging compared with 68% of nonanaemic patients (P = 0.03). There was no difference in nodal downstaging between the groups. The RCRG scores showed more tumour regression in nonanaemic patients than in anaemic patients, as follows: RCRG 1, 59%vs 30%; RCRG 2, 11%vs 17%; and RCRG 3, 38%vs 46% (P < 0.001).

CONCLUSION

The prevalence of anaemia in patients undergoing long-course neoadjuvant radiotherapy was 35%. Anaemia during long-course neoadjuvant radiotherapy was associated with significant reductions in tumour downstaging and regression.

Systematic review and meta-analysis of wound dressings in the prevention of surgical-site infections in surgical wounds healing by primary intention

BACKGROUND

Postoperative surgical-site infections are a major source of morbidity and cost. This study aimed to identify and present all randomized controlled trial evidence evaluating the effects of dressings on surgical-site infection rates in surgical wounds healing by primary intention; the secondary outcomes included comparisons of pain, scar and acceptability between dressings.

METHODS

Randomized controlled trials comparing alternative wound dressings, or wound dressings with leaving wounds exposed for postoperative management of surgical wounds were included in the review regardless of their language. Databases searched included the Cochrane Wounds Group Specialised Register and Central Register of Controlled Trials, Ovid MEDLINE, Ovid Embase and EBSCO CINAHL from inception to May 2011. Two authors performed study selection, risk of bias assessment and data extraction, including an assessment of surgical contamination according to the surgical procedure. Where levels of clinical and statistical heterogeneity permitted, data were pooled for meta-analysis.

RESULTS

Sixteen controlled trials with 2594 participants examining a range of wound contamination levels were included. They were all unclear or at high risk of bias. There was no evidence that any dressing significantly reduced surgical-site infection rates compared with any other dressing or leaving the wound exposed. Furthermore, no significant differences in pain, scarring or acceptability were seen between the dressings.

CONCLUSION

No difference in surgical-site infection rates was demonstrated between surgical wounds covered with different dressings and those left uncovered. No difference was seen in pain, scar or acceptability between dressings.

Fifth-year surveillance computed tomography scanning after potentially curative resections for colorectal cancer

INTRODUCTION

Optimal follow-up after colorectal resection for adenocarcinoma is yet to be determined. The aim of this study was to examine the role of a fifth-year surveillance Computed Tomography (CT) scan in detecting recurrence in our population.

METHOD

A retrospective analysis of all patients who had undergone potentially curative resections of colorectal adenocarcinomas between 2003 and 2004 was performed using electronic and casenote records. Data analysis was performed using Microsoft Office Excel 2007 and GnuPSPP statistical software.

RESULTS

Two hundred and seven patients (111 male and 96 female) with a median age of 74 years (IQR 66-80) undergoing colorectal resections were studied. One hundred and twenty-one patients (58%) were alive and disease free at 5 years of whom 81 (67%) had received a fifth-year surveillance CT scan. Fifth-year scanning did not demonstrate any new colorectal metastases. However 6 (7%) scans revealed new, undiagnosed, non-colorectal malignancies. Thirty-four patients developed metastatic disease. All metastasis were diagnosed by 3½ years of follow-up. Eleven of these 34 cases presented after their second-year surveillance CT scan. Those patients with asymptomatic metastasis at the time of their discovery demonstrated improved likelihood of five year survival.

CONCLUSION

This study showed no role for a fifth-year surveillance CT scan in the detection of resectable metastases, however there was a 7% pick up rate for detecting new malignancies. CT scanning beyond 2 years was needed to identify about one-third of the recurrences reported in this study.

Dressings for the prevention of surgical site infection

BACKGROUND

Surgical wounds (incisions) heal by primary intention when the wound edges are brought together and secured - often with sutures, staples, clips or glue. Wound dressings, usually applied after wound closure, provide physical support, protection from bacterial contamination and absorb exudate. Surgical site infection (SSI) is a common complication of surgical wounds that may delay healing.

OBJECTIVES

To evaluate the effects of wound dressings for preventing SSI in people with surgical wounds healing by primary intention.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (searched 10 May 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011 Issue 2); Ovid MEDLINE (1950 to April Week 4 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, May 9, 2011); Ovid EMBASE (1980 to 2011 Week 18); EBSCO CINAHL (1982 to 6 May 2011). There were no restrictions based on language or date of publication.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing alternative wound dressings or wound dressings with leaving wounds exposed for postoperative management of surgical wounds healing by primary intention.

DATA COLLECTION AND ANALYSIS

Two review authors performed study selection, risk of bias assessment and data extraction independently.

MAIN RESULTS

Sixteen RCTs were included (2578 participants). All trials were at unclear or high risk of bias. Nine trials included people with wounds resulting from surgical procedures with a contamination classification of 'clean', two trials included people with wounds resulting from surgical procedures with a 'clean/contaminated' contamination classification and the remaining trials evaluated people with wounds resulting from various surgical procedures with different contamination classifications. Two trials compared wound dressings with leaving wounds exposed. The remaining 14 trials compared two alternative dressing types. No evidence was identified to suggest that any dressing significantly reduced the risk of developing an SSI compared with leaving wounds exposed or compared with alternative dressings in people who had surgical wounds healing by secondary intention.

AUTHORS' CONCLUSIONS

At present, there is no evidence to suggest that covering surgical wounds healing by primary intention with wound dressings reduces the risk of SSI or that any particular wound dressing is more effective than others in reducing the rates of SSI, improving scarring, pain control, patient acceptability or ease of dressing removal. Most trials in this review were small and of poor quality at high or unclear risk of bias. However, based on the current evidence, we conclude that decisions on wound dressing should be based on dressing costs and the symptom management properties offered by each dressing type e.g. exudate management.

Enhanced recovery in colorectal resections: a systematic review and meta-analysis

OBJECTIVE

The study aimed to produce a comprehensive up-to-date meta-analysis exploring the safety and efficacy of enhanced recovery (ER) programmes after colorectal resection.

METHOD

Key-word and MESH-heading searches of MEDLINE, EMBASE and the Cochrane Databases from 1966 to February 2007 were used to identify all available randomized and clinical controlled studies. Two independent reviewers assessed studies for inclusion and exclusion based on methodological quality criteria prior to undertaking data extraction. Summary estimates of treatment effects using a fixed effect model were produced with RevMan 1.0.2, using weighted means for length-of-stay data and relative risks of morbidity, mortality and readmission rates.

RESULTS

Analysis of four papers including 376 patients demonstrated primary and total length-of-stays (primary + readmission length-of-stay) to be significantly reduced (P < 0.001) with ER programmes [weighted mean differences of -3.64 days (95% confidence interval, 95% CI -4.98 to -2.29) and -3.75 days (95% CI-5.11 to -2.40)]. Analysis of controlled clinical trial data showed morbidity rates to be reduced and readmission rates increased. These trends were not seen amongst the randomized controlled trial data. There were no differences in mortality rates.

CONCLUSION

Enhanced recovery programmes after colorectal resections reduce length-of-stay and may reduce 30 days morbidity and increase 30 days readmission without increasing mortality.

Prophylactic perifoveal laser treatment of soft drusen

PURPOSE

To assess the efficacy and safety of perifoveal laser to cause drusen to resorb, and establish a treatment protocol.

METHODS

Treatment technique was determined by the outcome in one patient with 15-year follow-up. In an uncontrolled series a perifoveal ring of gentle laser was applied to 30 eyes of 28 patients, 18 with bilateral drusen and 10 with exudative disease in the fellow eye. Comparison was made between treated and untreated eyes in 14 patients with bilateral drusen. Mean follow-up was 16.8 months (range, three to 42 months).

RESULTS

Soft drusen resorbed in all treated eyes in the vicinity of laser and within the fovea. Large soft confluent drusen (> 500 microns) responded most rapidly. Visual acuity improved one or more lines in 12 (40%) treated eyes, was unchanged in 16 (53%) and deteriorated in two (7%). In 14 patients with bilateral drusen in whom only one eye was treated, VA remained unchanged in 10 eyes and improved in four treated eyes while none of the untreated eyes improved (P = 0.03, chi 2) and decreased in four eyes. Atrophic expansion of laser burns was minimal. CNV developed in two of 30 eyes (7%).

CONCLUSION

Perifoveal laser treatment appears to expedite the regression of soft drusen within the fovea. The risks of complications may be reduced by treating eyes early, before pigment changes develop and by applying a minimum number of burns at a distance greater than 750 microns from the foveal centre. Treatment should currently be administered only in the context of a prospective clinical trial, which is required to assess whether this treatment results in lowered risk of visual loss from CNV or geographic atrophy.

Disc leak in the pathogenesis of posterior retinal degenerations

Pathogenesis of the posterior retinal degenerations and the role of argon laser para-disc coagulation in its treatment. The posterior retinopathies sometimes follow the degeneration of the retinal pigment epithelium with a release of the hypothetical vasoproliferative factor. There is clinical evidence to show that a slow degeneration of the retinal pigment epithelium also produces a vasoproliferation from the circulation which comes from the choroidal vessels supplying the disc. Treatment by argon laser at the disc margin inhibits the rate of degeneration, and extension of the vasoproliferation.

Modified narcosis, ECT and antidepressant drugs: a review of technique and immediate outcome

The renewed use of modified forms of narcosis, generally given together with ECT and antidepressant drugs, arose from a series of observations made during attempts to treat a group of chronically tense patients. These patients, the majority of whom had been diagnosed as ‘chronic tension states', had been referred to the Department of Psychological Medicine at St. Thomas' Hospital for assessment regarding their suitability for modified leucotomy. Birley (1964), in a follow-up study of previous patients with ‘tension states' treated by leucotomy at St. Thomas' Hospital, had found that many developed clear-cut attacks of depression following the operation. This suggested to one of us (W.S.) that such ‘tension states' might have been masked depressive illnesses, in whom the underlying diagnosis had been missed. Consequently it was decided that in the future such patients should be treated with suitably long courses of ECT, together with one or both groups of antidepressant drugs, before any question of recommending leucotomy arose. As a result, a considerable number of these patients were greatly improved and no longer required a leucotomy. Others, however, became more tense and distressed during treatment with ECT and drugs; modified narcosis, therefore, was given in addition, to allow the full course of ECT to be completed. It was then that another of us (C.W.) observed that patients who were treated with combined narcosis, ECT and antidepressants appeared to respond more favourably, and were much less upset by the treatment, than those receiving ECT and antidepressants alone. In a preliminary report published in 1966, Sargant, Walter and Wright described a group of 73 patients with ‘chronic tension states', of whom 67 per cent had improved markedly with further treatment of their underlying depression. It was noted that 15 of the 37 patients treated with ECT and antidepressants alone still required a leucotomy, while in the group treated with modified narcosis in addition to ECT and antidepressants the operation was needed in only 3 of the 36 patients. It appeared, therefore, that the addition of narcosis to drugs and ECT greatly improved the recovery rate.

Modified leucotomy assessed clinically, physiologically and psychologically at six weeks and eighteen months

After more than thirty years the operation of leucotomy still remains a controversial treatment, and its value is questioned by many. This scepticism, and the advent of new surgical techniques, have emphasized the need for careful appraisal of the results of psychosurgery. In a previous prospective study 40 patients were assessed six weeks after modified leucotomy, and 75 per cent of these patients were found to be clinically improved (Kelly, Walter and Sargant, 1966). They were less neurotic on the M.P.I., had lower Taylor Manifest Anxiety scores and rated themselves as less anxious; a good clinical outcome was associated with diminution of physiological arousal as measured by forearm blood flow and heart rate. This group has now been followed-up and reassessed 18 months after operation, and a further group of 38 patients has been examined before, and again six weeks after, leucotomy. The data from the two groups have been combined to determine the immediate outcome for various diagnostic categories, and a multiple regression has been performed to elicit which of the pre-operative factors predict a favourable post-operative result.

A clinical and physiological relationship between anxiety and depression

There has been a great deal of argument during the past 30 years about the symptomatic differences between anxiety and depressive states. Mapother (1926) thought that anxiety states should be regarded merely as one of the numerous sub-divisions of the manic-depressive illnesses, since they merged through a series of patients into agitated depression. Lewis (1966) too saw no sharp division between anxiety states and depression and classified agitated depression and anxiety states together as one sub-division of the affective disorders. Garmany (1956, 1958) and Mayer-Gross, Slater and Roth (1960), however, felt that anxiety states and depression were basically different forms of illness.

The relationship between clinical diagnosis and anxiety, assessed by forearm blood flow and other measurements

Anxiety may be present to a greater or lesser degree in almost every psychiatric syndrome. The ability to quantify the degree of anxiety present in an individual patient has important implications for diagnosis, treatment and prognosis. Accurate clinical assessment of anxiety is by no means an easy task, although many psychiatrists believe it to be. If no other methods are used, there is no way of knowing how often an individual clinician is right or wrong. However, if several independent methods of assessing anxiety are used, more data are available, and a better overall judgment on an individual patient can be made.

Effect of L-triiodothyronine and chlorpromazine on ankle reflex time and a clinical thyroid scale in schizophrenics and controls

Claims have been made that thyroid hormone treatment benefits some schizophrenic patients. Earlier studies reported the use of dried thyroid in a dose of 48 gr. (2·9G) daily in a schizophrenic (Hoskins and Sleeper, 1929) and in other psychiatric states up to 60 gr. (3·6G) daily (Minski, 1927), but recent papers describe the use of l-triiodothyrgnine in place of dried thyroid in treating schizophrenics (Lochner, Scheuing and Flach, 1963; Flach, Celian and Rawson, 1958). Huxley, Mayr, Osmond and Hoffer (1964) believe that schizophrenics are more resistant to the effects of some physiological substances, including thyroxine, as part of a genetic polymorphism.

Modified leucotomy assessed by forearm blood flow and other measurements

The value of modified leucotomy in the treatment of psychiatric disorders is undergoing constant reappraisal. Ever since 1948 efforts have been made in the Department of Psychological Medicine of St. Thomas's Hospital and at Belmont Hospital to modify operative techniques and to learn more about the proper and discriminative selection of suitable patients within very varied diagnostic categories. A leading article in the British Medical Journal has called for renewed efforts along such lines. (Editorial, 1965). To enable various surgical procedures to be assessed and their merits and disadvantages compared more accurately, better objective methods of evaluating the effects of the operation are certainly required. Although several studies have been directed towards the measurement of intellectual function before and after operation (Mettler, 1949; Mettler and Landis, 1952; Tow, 1955) much less attention has been directed towards the objective assessment of personality changes and measurement of the reduction of key symptoms such as anxiety. Sykes and Tredgold (1964) emphasized what has been repeatedly stressed from this Department (Sargant, 1946, 1962; Sargant and Slater, 1944, 1948, 1954, 1963), that a decision to operate must take careful note of the individual symptoms, especially the degree of tension present. Falconer and Schurr (1959) consider that “the indication for operation should be, not the diagnostic label, but the tension and anxieties which the illness has produced”.